Having done most of my clinical clerkships in New York City, I came to Boston for residency expecting a similar experience in another metropolitan city. The culture of the Psychiatric Urgent Care units I observed in NYC consisted of a triage system in which some patients would be discharged and some, with enough evidence, (which is likely suicidal ideation, homicidal ideation or severe psychosis) would be admitted. Some patients would be in that area between admission and discharge. For those in-between situations, there was a statewide program available in some, but not all, hospitals called the Comprehensive Psychiatric Emergency Program (CPEP). CPEP is essentially an observation and holding area in the emergency room where patients needing further observation would be kept for up to 72 hours prior to discharge. Not surprisingly, it is often used as a quick and dirty detox “program”. This concept is common in EDs nationwide without a title or a special room. They are not “comprehensive” in other EDs around the nation, as these patients sober up and leave in much less than 72 hours, many times without a psychiatric assessment and are likely to return soon.
Thus, one could imagine the surprised look on my face when, during one of my first few calls as a resident, I heard my senior’s sign out to the admitting floor: “This is mainly a detox and humanitarian transfer. The patient is homeless and suffering from long term alcohol dependence.” Humanitarian admission due to alcohol dependence and homelessness, I wondered? What was the clinical judgment used here? This is not a hotel, it is a hospital, I thought to myself.
During rounds the next morning, I heard the attending speak of our “mission to end homelessness.” As a new physician, I was still in the inquiry mode, thinking like an engineer, wondering what is the problem we are treating and why is our homeless and alcohol-dependent patient still here? As much as I liked that mode, however, the attending’s words resonated with another part of me, which I had, perhaps, ignored for a few years. This situation took me back to my public health training days and my idealistic dreams as a graduate student. Dr. Cousineau, my mentor at the University of Southern California Keck’s School of Public Health, who works on impact of health policy on the homeless helped instill the same vision in me: to eliminate homelessness. While skeptical about the practice of medicine I had just witnessed, I thought about other idealistic “what ifs”: What if I could securely access my patient’s records all day, every day, and anywhere in the world so that I could make myself available to oversee their care regardless of where I was in the world? What if I could assure my patients’ continuity of care in any state as long as they walk into a hospital and request for help? Their previous records would be available, my recommendations, their active medication list, everything!
What if I could access the notes from multi- disciplinary medical professionals to know what they were doing for my patient as well? After all, knowing what his/her primary care and neurologist are doing could really help me out when I am deciding on my treatment plan and options. What if I could share my notes with other providers by just looking them up and “tagging” them on my notes much the same way you tag a person on a Facebook photo, and maybe even get them to acknowledge receipt of my note by an electronic signature?
What if I had a system that would automatically send me alerts (again like Facebook) when people wanted me to read a note or when things were wrong? For instance, if I ordered labs that came back with abnormal values or if the pharmacist wanted me to fix a mistake on the prescription I had written. Similarly, what if there was a system that would alert me of any med-med interactions before I signed a script?
What if I could click a button and see all the medications my patient had tried in the past? Instead of suggestions or referral with a business card, what if I could place outpatient consults that would generate automatic appointments for my patients and those specialists could also read my patient’s history?
What if…what if? And what if I told you that while the elimination of homelessness has not yet occurred the rest of the “what ifs” are the reality of today’s VA healthcare system. Dream no more! This system has existed long before Facebook ever did and mainly due to the nationally available, VPN connected, and tightly monitored and secured electronic medical record system.
This system is so natural to use and so obviously needed that, much like a beating heart, I used it for months without thinking about the miracle it actually was. During these months I further learned to think less like an engineer and more like a psychiatrist: one who considers the “bio,” the “psycho,” and the “social” aspects of the patients. I learned that in order to carryout care in a holistic manner, continuity of care, history, collateral information, and communication between providers are essential elements. In conclusion, I witnessed that the VA’s success in delivering mental healthcare to patients in such fashion is owed to the organization’s two major strengths:
One is the VA’s culture of provision of care: All honorably discharged veterans receive quality care regardless of disease, severity, and socio economic status (notice insurance companies have been minimized in this system—a separate debate not discussed here.) No matter where one lies on Obama’s Affordable Care Act, providing an “all-inclusive quality of care to all US citizens and residents’ is nothing more than an idealistic dream by most providers, yet provision of care to all honorably discharged veterans is a reality for VA Clinicians. All the while, the VA healthcare system rates quite high on objective quality measures as well.
For example, in the case of our original dual-diagnosis patient, VA clinicians know that a 24 to 72 hour detox at the “Comprehensive” Psychiatric Emergency Program, while a great band aid, will do nothing to treat the underlying problem of substance dependence and/or the comorbid mental illness. The ‘quick and dirty’ is replaced by a system that enables us to educate you and provide options for mental healthcare, long-term abstinence programs, and housing. There will be those who will abuse the system and sign out AMA. However, our job as doctors is to treat the core of the disease and not just the symptoms. Additionally, the patient who signed out AMA after a shower could transition from pre-contemplation to contemplation due to the brief motivational interviewing between admission and his shower. Every interaction is a chance for intervention.
The VA system of mental health is one which caters to patients’ needs, even if that need is to be “taken in and taken care of” at any stage. This system has invested heavily in preventive, rehabilitative and population-based care. It is a public health model that deserves further discussions for adaptation by other healthcare institutions. “You are not alone, we are here to help” is what I learned to say to my patients after the end of my first year as a resident in the VA system, and I meant it.
The second strength of the VA system is that it has the technology and tools needed to deliver high quality of care to all US veterans. The VA electronic medical record system is the largest, most inclusive and secure system used in this country. Patients move across the country and their care is transferred instantly. If patients visit other states, their health records are available at a moment’s notice. New developments also include creating phone apps for veterans and, through telehealth, bringing mental health into the homes of patients who have trouble coming to clinic. Use of such technology should be standard of practice in the 21st century, especially within the most technologically advanced country in the world.
The VA’s mental health system operates in a way that all healthcare systems should: It focuses on the long-term, as opposed to looking only at short-term solutions. It looks at the bigger picture and addresses the core of the problems. The VA mental health care system expects and delivers higher quality of care and comprehensiveness that is a standard of care nationwide.
The above certainly will leave many with the reflexive question of “who will pay for this?” The hospitals, healthcare providers, government, and taxpayers are the ones who will pick up the tab left by those undertreated. The citizens are the ones who fund public programs, such as Medicaid, which will ultimately pay for the circular cost of ‘band aid care.’ The extra work done to help these revolving-door emergency-room patients falls on the shoulder of providers as well. Therefore in one-way or another, we are all paying for our healthcare system. What we should aim for is efficiency and cost-effectiveness. These goals are achieved through coupling technology with comprehensive care (including preventive care- not fully discussed here). The VA system for mental health care successfully manages and caters to some of the most complex and seriously mentally ill patients using this motto. Additionally, it addresses cost avoidance by dealing upfront with broken lives that would otherwise end up in ERs or ICUs over decades.
While many aspire to look to outside countries such as Canada or the United Kingdom, to piece together the good in order to reform our healthcare system, one should not forget to look at the VA system and especially the mental health division of this system. The model we should further study and learn from when we think of “reform for provision and continuity of care” is as American as the Federal Government’s VA system and has been a very large “pilot” here at home. It is advanced culturally and technologically, has passed the test of time, and it works by making life better for providers through making it better for patients.
(This article first appeared in the Massachusetts Psychiatric Society Newsletter, Issue 137, September 2013.)
Edwin Raffi, MD, MPH is a resident physician at the Harvard South Shore Psychiatry training program and a Member In Training co-leader for the Massachusetts Psychiatric Society VA Committee.
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